Letters Sent to Physicians Cut Antibiotic Prescribing by 3%

Marcia Frellick

February 19, 2016

Sending a letter to the general practitioners (GPs) in the United Kingdom who had high rates of prescribing antibiotics resulted in a 3.3% drop in prescribing over the course of 6 months, according to a study published online February 18 in the Lancet.

The letters, sent to 3227 GPs, had three key features: They reported that 80% of practices in the local area prescribed fewer antibiotics than the physician did, they came from England's chief medical officer, and they listed three specific actions the GP could take to reduce unnecessary prescriptions. Those actions included giving patients advice on self-care, offering to delay the prescription, and talking about prescribing with other clinicians in his or her practice.

Lead author Michael Hallsworth, from the Behavioural Insights Team in London, United Kingdom, and colleagues found that between October 2014 and March 2015, the rate of antibiotic items dispensed per 1000 population was 126.98 (95% confidence interval [CI], 125.68 - 128.27) in the feedback intervention group and 131.25 (95% CI, 130.33 - 132.16) in the high-prescribing control group that did not receive a letter, for a difference of 4.27 (3.3%; incidence rate ratio, 0.967; 95% CI, 0.957 - 0.977; P < .0001).

The authors estimate that the intervention resulted in 73,406 fewer antibiotic prescriptions being dispensed during the study period than would have occurred without the intervention.

Low Cost for Each Prescription Prevented

The researchers calculated the cost of printing and mailing the letters to 3227 GPs in 791 practices at £4335, which equals £0.06 per prescription prevented during the study (excluding the time costs of implementing the intervention).

"Giving tailored feedback to prescribers isn't complicated," Hallsworth said in a journal news release. "We estimate that this simple intervention could reduce England's antibiotic prescribing by 0.85% overall, despite costing just 6p per prescription saved. This kind of feedback could also be provided for many other kinds of drugs, and by anyone who is interested in doing so, since all this information is publicly available online," he added.

The second half of the trial tested the effect of a patient education campaign, including posters or leaflets that promoted reduced use of antibiotics, but researchers found that the patient-focused intervention did not significantly affect the primary outcome measure.

Intervention Would Need to Be Regionally Tailored

The study clearly shows promise, Ian M. Gould, MBChB, FRCPE, MRCPath, from the Department of Medical Microbiology, Aberdeen Royal Infirmary, and Timothy Lawes, MSc, from the Royal Aberdeen Children's Hospital, United Kingdom, write in an accompanying comment.

"The national scale, pragmatic trial design, and low cost of the intervention suggest that social norm feedback could be effective and cost-saving in other settings," they write.

However, they note strong caveats, including that in the United Kingdom, which has universal healthcare, the cost of obtaining and comparing prescribing data are low. But in countries such as the United States, with multiple providers, comparisons are more difficult.

They also note that, "Where health insurance or out-of-pocket expenditures predominate, doctor reputation and income depend upon answering patients' expectations for antibiotics."

Advantages of this study are its large scale and that it took place in a live policy context, which strengthens its external validity.

Study Did Not Measure Health Outcomes

One limitation of the study is that it does not measure health outcomes.

"[W]e cannot measure whether the reductions in antibiotic prescribing occurred only for infections for which antibiotics are ineffective (although the subgroup analyses suggest that this is the case). However, previous reviews have reported no negative effects of antibiotic stewardship interventions on treatment effectiveness or patient satisfaction," the authors write.

Editorialists Dr Gould and Lawes say a bigger limitation may be the 6-month trial period.

"It is not clear whether reiteration would be equally effective and whether, given time, it would shift, or merely narrow, the national antibiotic prescribing distribution."

England's chief medical officer, Public Health England, the Department of Health, and the Behavioural Insights Team collaborated on the trial.

The study was funded by Public Health England. Dr Gould has received consultancy and lecture fees from Bayer, Cubist, MSD, AstraZeneca, Novartis, Pfizer, and Clinigen; consultancy fees from The Medicines Company, Basilea, and GenMark; and nonfinancial support for consultancy from BioMérieux and Cepheid. As president of the International Society of Chemotherapy, Dr Gould frequently requests meeting support from a wide range of diagnostic and pharmaceutical companies, including many of those involved in the manufacture of diagnostics and antibiotics for methicillin-resistant Staphylococcus aureus.

Lancet. Published online February 18, 2016. Article full text, Comment full text


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